Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, M.D.
12 June 2002

WHO IS GOING TO DRIVE?

     Over the years, concepts of medical care changed quite dramatically.  During my training in the 1960’s, I recall going on teaching rounds with a kindly, very confident, well intended professor of medicine.  He not only taught the medical students but he would educate the patients by discussing their case at the bedside indicating which medical steps were important in that patient’s care.   The professor’s attitude was what might be called “paternalistic”.  Like a father, he felt that he knew what was best for this patient, what the medication should be, what the doses should be and what health practices the patient should adopt.  While the professor was very knowledgeable, he probably spent less than  half an hour with each individual patient,some portion of that listening to the patient’s story and considering the laboratory data.  In that brief half hour, he would come up with a life plan for this person.  This paternal “father knows best” model for medical care dates back many years and was certainly the attitude in the 1960’s.  Since then, I have become a father with children and then grandchildren.  It was my experience that paternalism didn’t work worth a hoot in raising my kids.  No matter what I thought, my kids always  seemed to have ideas of their own and they weren’t at all shy about letting me know about it.  In these last 40 years, paternalism in medical care has probably become less effective than it was in raising kids.

       Independent of the technical difficulties of practicing medicine, communicating with a patient and satisfying that person’s needs is the most critical part of medical care.  No matter how good the medical advice might be, if the patient doesn’t buy into it, the advice serves no useful purpose no matter how well intended.

    In today’s world, the model of medical care is rather like driving a vehicle.  If you were going to get in a vehicle and go someplace, perhaps the first question to ask is, “Who is going to drive?”  Is the healthcare professional going to be the driver or is the patient going to be the driver.  In today’s more sophisticated world with the Internet and more medical information than one can ever read, the patients often have their own ideas on what the right diagnosis is and how to treat it.  As an example, a gentleman recently came to the clinic stating that he was sure that the Lipitor that he was taking to treat his high blood cholesterol was causing him to have muscle aches and he wanted to stop the Lipitor.  He had already had coronary artery bypass surgery once, a stent placement four years later and was having chest pain with exertion now.  Often when a person comes in and says they want to stop a medication, it means that they have already stopped it and they are just looking for approval.  In this particular case, the gentleman hadn’t stopped the medication and after a long discussion, he said that is what is was going to do.  I told him that I didn’t agree with his conclusions and that the choices would be his own.  He did stop the medication for a month and on returning said that his muscle aching wasn’t any different and he wondered if the Lipitor could still be having an effect.  I did not support him in that idea either.  I pointed out that his cholesterol had increased very substantially in the month without the medication.  He wondered what he should do.  I made the analogy above about driving the vehicle and told him that it seemed to me that he was the driver right now.  I had given him the advice on what I thought should be done but he was driving his own route.  He became somewhat indignant at that point and said, “Well, you’re the doctor.”  I pointed out to him that he was the driver at this point and he wasn’t even listening to my directions.  It took awhile for that comparison to sink in.  Eventually, we reached an understanding that the destination that he was seeking was avoidance of his chest pain, effectively dealing with his heart disease and avoiding the next heart attack.  With that as a destination, he then understood that the directions could come from the “shotgun seat” since he wasn’t getting to the destination that he wanted.

     What would it be like if instead of a car, the vehicle was an airplane and the patient had never flown before?  Now it doesn’t make a whole lot of sense for the patient to be the driver (pilot).  The pilot can listen to directions from the person “riding shotgun” but flying the plane becomes the responsibility of the healthcare professional.  Here the problem becomes confusing directions.

     As an example, a lady came to the clinic because she had found a lump in her breast. The lump was biopsied and found to be a cancer.  After evaluation, it was found that the problem could most likely be treated very effectively with a simple medication called Tamoxifen.  She said that she had heard that that was a form of chemotherapy and that isn’t what she wanted to do.  She wasn’t seen for about one year and on her return, the malignancy had involved her spine and was causing severe back pain.  She maintained very firmly that she did not want to use chemotherapy.

     This is rather like getting in the car and telling the driver you don’t want to go to town. The driver might ask, “Where do you want to go?”

       The patient replies, “I don’t want to go to town.”

     Telling the driver where you don’t want to go, doesn’t get you any place.  After long discussions with this lady and using the analogy above, she began to understand that I needed some direction in what she did want to do; telling me what she did not want  left us still going no place.  Eventually, she was willing to accept the idea that Tamoxifen was the best treatment for her and fortunately, it did put her cancer into a remission and resolved her back pain. As though the above two problems aren’t enough, now we have the insurance company, Medicare Regulations, and the HMO’s influencing the driver also whether the driver is the patient or the healthcare professional.

       Today, the best model for healthcare requires an understanding between the patient and the healthcare provider as to who is going to drive and who is going to ride.  Some patients don’t even want the healthcare professional in the vehicle and the patient makes their own decisions. Others invite the healthcare professional along as an advisor and a person to give directions whether the directions are followed or not.  Some patients (drivers) need and want and even listen to directions from the healthcare provider.  To me, this is the best model.

     Alternatively, the patient may not have a clue on how to drive this vehicle.  I wouldn’t try and drive one of those fancy farm tractors myself but I might tell the driver which field I want plowed and what I want planted.  In those situations, it is akin to the patient letting the healthcare professional know what their destination would be, the route they might want to take, how fast they want to drive, and maybe even which vehicle they would like to ride in.  These considerations require good communication between the healthcare provider and the patient. This is best done through your local clinics who can coordinate your healthcare and call in for specialists as needed.  Coordination of the medical care through your local clinics is very clearly the best model for managing your healthcare.  A specialist, like an airline pilot, isn’t the person who decides where you should go; he merely gets you there once you have decided where you want to go and how you want to go.  That decision is best made through your local healthcare professionals.